Mrs. Reena, 55 years female come to emergency departmentwith the history of fever and head ache, breathing difficulty andnot able to eat. The nurse in emergency department checked hervital signs

Temperature: 101F

Pulse: 88/minute

Respiration:/minute

The physician collected history from the patient and recommendedblood test, urine test and chest x ray.

The doctor written following treatment

Oxygen administration; 3L/minute

Tab: Paracetamol; 500mg TDs

Inj. Amoxicillin, IV, 500mg, BD

Normal Diet with more liquid

The nurse applied cold compression over the forehead

Provided the ventilation

Administered the antipyretic drug as per physician order

Administered IV antibiotic medicine

Checked vital sign for every hours

Provided comfortable position

Inform the dietician to provide Soft solid diet with moreliquids

And for breathing difficulties

Administer Oxygen, place patient in semi – fowlers position andchecked oxygen saturation regularly

And informed respiratory therapist to provide chestphysiotherapy and breathing exercise to prevent accumulation ofmore secretion .If secretion in the respiratory tract is notremoved patient is having risk to get ineffective breathing patternbecause of secretions accumulated in the respiratory tract.

Assessment

Nursing diagnosis

goal

Nursing intervention

Rationale

Evaluation

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